Explanation of Decubitus Ulcers A decubitus ulcer is a pressure sore or what is commonly called a "bed sore".

It can range from a very mild pink coloration of the skin, which disappears in a few hours after pressure is relieved on the area, to a very deep wound extending to and sometimes through a bone into internal organs. These ulcers, as well as other wound types, are classified in stages according to the severity of the wound. All decubitus ulcers have a course of injury similar to a burn wound. This can be a mild redness of the skin and/or blistering, such as a first-degree burn, to a deep open wound with blackened tissue, as in a third degree burn.

Mechanism of Formation The usual mechanism of forming a decubitus ulcer is from pressure. However it can also occur from friction by rubbing against something such as a bed sheet, cast, brace, etc., or from prolonged exposure to cold. Any area of tissue that lies just over a bone is much more likely to develop a decubitus ulcer. These areas include the spine, coccyx or tailbone, hips, heels, and elbows, to name a few. The weight of the person's body presses on the bone, the bone presses on the tissue and skin that cover it, and the tissue is trapped between the bone structure and bed or wheelchair surface. The tissue begins to decay from lack of blood circulation. This is the basic formation of decubitus ulcer development. Causes: Pressure on the skin reduces blood flow to the area. Without enough blood, the skin can die. An ulcer may form. You are more likely to get a pressure ulcer if you:

Use a wheelchair or stay in bed for a long time Are an older adult Cannot move certain parts of your body without help because of a spine or brain injury or disease such as multiple sclerosis Have a disease that affects blood flow, including diabetes or vascular disease

Symptoms of a pressure ulcer are:

Red skin that gets worse over time The area forms a blister, then an open sore

Pressure sores most commonly occur on the

Elbow Hips Heels Ankles Shoulders Back Back of head

Pressure sores are grouped by their severity. Stage I is the earliest stage. Stage IV is the worst.

Stage I: A reddened area on the skin that, when pressed, does not turn white. This is a sign that a pressure ulcer is starting to develop. Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated. Stage III: The skin now develops an open, sunken hole called a crater. There is damage to the tissue below the skin. Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints.

Prevention If you are on bedrest or cannot move because of a medical condition, someone should check you for pressure sores every day. You or your caregiver should examine your body from head to toe. Pay special attention to the areas where pressure ulcers often form. Look for reddened areas that, when pressed, do not turn white. Also look for blisters, sores, or craters. Take the following steps to prevent pressure ulcers:

Change position at least every 2 hours to relieve pressure. Use items that can help reduce pressure -- pillows, sheepskin, foam padding, and powders from medical supply stores. Eat well-balanced meals that contain enough calories to keep you healthy. Drink plenty of water (8 to 10 cups) every day.

Exercise daily, including range-of-motion exercises. Keep the skin clean and dry. After urinating or having a bowel movement, clean the area and dry it well. A doctor can recommend creams to help protect the skin.

5. Positioning on chair/wheelchair should include 1. Have an assistant ready to help with moving the patient from the wheelchair and into the bed. If available, set up and position the hoyer lift to transfer the patient out of the chair.

2. Position the patient on his side with the ulcer closest to you for treatment. Have your assistant with the patient to ensure he does not move out of position or injure himself from rolling. 3. Clean the ulcer first with a saline solution and check for any dead skin. Debride (remove dead skin) as needed around the wound carefully.

4. Apply dressings as needed to the ulcer. A dressing such as a hydrocolloid works best as it promotes skin growth and maintains moisture around the wound.

5. Place the wheelchair cushion onto the seat of the chair for the patient so that it will be in place when you return them to their chair. The cushion will help relieve pressure against the part of their body that is prone to sores as well as protect the bandaged ulcer. With the help of your assistant or a hoyer lift, return the patient to his chair.

a.Postural alignment A postural support system that maintains the trunk as nearly vertical as practical and effectively resists kyphoscoliotic collapse has a profound effect on management of both pressure and shear. The more erect posture moves the upper body weight anteriorly and makes it possible to bear that weight on the more pressure-tolerant areas of the proximal thighs. Lateral thoracic support is often necessary to control lateral lean. More than one support may also be used in asymmetrical combination to help resist scoliotic spine collapse. Lumbar support is essential to resist kyphotic collapse but must be used in conjunction with a pelvic recess in the seat bottom. Otherwise, the pelvis is simply pushed forward.

b.Distribution of weight Pressure The factor which has been assumed primary for many years is simple pressure, acting roughly perpendicular to the skin surface. The popular interpretation of physiologic events is that when the pressure on tissues exceeds blood capillary pressure, blood cannot carry nutrients to the tissue cells. Also, of course, waste products cannot be transported away from the cells. It is fairly easy to understand that if excessive pressure deprives tissue cells of nutrients long enough, they exhaust available nutrition and begin to die. Any relief of the offending pressure before necrosis has proceeded will allow nutrients back into the area and waste products to be carried off, giving the tissues a new lease on life. The length of that "new lease" depends upon how much blood transport has occurred during the pressure relief. In fact, if the pressure variations are frequent enough, they can act as a pump, actually aiding circulation. The total support area, however, is only part (sometimes a minor part) of what determines the magnitude of pressures at bony prominences. Pressures vary over the support surface depending upon how close the skeleton is to the skin surface. Sitting pressure measurements vary significantly more for paraplegic and elderly people than for neuromuscularly healthy people even though median pressure values are similar (5). This may be due to generally lower muscle tone and widely variable amounts of fatty "padding." Body build also affects the pressure distribution. It is more likely that thin people have a high pressure area over a bony prominence than people of average or above-average weight (11). A reduced level of compliance (or "softness") at isehial tuberosities, for instance, causes those areas to bear a greater portion of the load. When the hamstring muscles are tensed or in spasm, they are less compliant, and those posterior thigh tissues will then bear a greater portion of the total weightbearing load. c.Balance @stability

d.Pressure relief Redistributing pressure can be achieved with repositioning and support surfaces.

The frequency of repositioning is unknown and lacks scientific evidence. However, the same Cochrane review also states that two hours in a single position is the maximum duration of time recommended for patients with normal circulatory capacity. Reposition and turn; regularly and frequently. Utilize positioning devices (e.g., pillows, foam wedges) to avoid placing the patient on the pressure ulcer or other areas at risk for pressure ulceration. Place cushioning devices or pillows between legs/ankles and other bony prominences to maintain alignment and prevent touching of bony prominences. When side lying, use a 30-degree laterally inclined position to relieve pressure over the trochanter. 1. Support surfaces: Beds Based on the current research, it is impossible to determine the most effective support surface for the treatment of pressure ulcers. Pressure redistributing surfaces are recommended for individuals with full thickness (i.e., stage III/IV pressure ulcers) or ulcers that involve multiple turning surfaces. For patients with large stage III or IV pressure ulcers or ulcers on multiple turning surfaces, a low-air-loss or air-fluidized surface may be indicated. Chairs There is no one seating cushion that is better than another for individuals with pressure ulcers. There is some evidence to suggest that certain wheelchair cushions (i.e., static versus dynamic [nonpowered vs. powered]) can result in decreased seating interface pressure and decreased skin temperature. Specialized pressuremapping to assist with individual wheelchair cushion selection is recommended. Currently there is a lack of standardization in how pressure mapping readings are reported by different devices. A standardized testing methodology for pressure redistribution surfaces is needed to compare products and choose the best product for the patient.

III. Mechanical Loading and Support Surfaces 1. Reposition bed-bound persons at least every 2 hours, chair-bound persons every hour. 2. Use a written repositioning schedule. 3. Place at-risk persons on a pressure-reducing mattress/chair cushion. Do not use donut-type devices. 4. Consider postural alignment, distribution of weight, balance and stability, and pressure relief when positioning persons in chairs or wheelchairs. 5. Teach chair-bound persons, who are able, to shift weight every 15 minutes. 6. Use lifting devices (e.g., trapeze or bed linen) to move rather than drag persons during transfers and position changes. 7. Use pillows or foam wedges to keep boney prominences such as knees and ankles from direct contact with each other. 8. Use devices that totally relieve pressure on the heels (e.g., place pillows under the calf to raise the heels off the bed). 9. Avoid positioning directly on the trochanter when using the side-lying position (use the 30 lateral inclined position). 10. Elevate the head of the bed as little (maximum 30 angle) and for as short a time as possible.